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PubMed1997

Cost-effectiveness of mandatory stress testing in chest pain center patients.

STUDY OBJECTIVE: To determine whether emergency patients with acute chest pain and low suspicion of acute myocardial infarction (AMI) can be managed cost-effectively and safely in a dedicated chest pain center (CPC) that incorporates mandatory stress testing. METHODS: We assembled a prospective observational case series of consecutive adult patients transferred from the emergency department to a nine-bed, 23-hour CPC in a 564-bed community hospital from January 13 through May 31, 1994. In our institution, all emergency patients with acute nontraumatic chest pain of unclear origin, suggestive of myocardial ischemia but with a low probability of AMI, are transferred to the CPC for further evaluation. All patients in whom AMI is ruled out undergo individually appropriate cardiac diagnostic testing in accordance with CPC clinical guidelines. Patients with end-stage coronary artery disease transferred to the CPC for a "rule-out" protocol only did not undergo further diagnostic testing. Admitted and discharged patients were followed through chart review and telephone survey, respectively. RESULTS: Of the 502 patients transferred to the CPC, 477 (95%) completed follow-up at 14 days. Four hundred ten (86%) were discharged home. Those discharged after diagnostic evaluation yielded negative findings had 100% survival and zero diagnosis of AMI at 5-month follow-up. Overall mortality and incidence of AMI on long-term follow-up for all patients transferred to the CPC were .4% and .2%, respectively. Sixty-seven patients (13%) were admitted from the CPC, of whom 44 (66%) had a final diagnosis of ischemic heart disease (IHD) or AMI. Twenty-four patients with IHD (55%; 6% of stress-tested group) were identified only on further stress testing. Of these patients, seven underwent percutaneous transluminal coronary angioplasty or coronary artery bypass grafting during hospitalization. All were discharged home without major morbidity. Four hundred twenty-four patients (84%) underwent stress testing. The cost of mandatory stress testing to identify one patient with IHD after AMI was ruled out was $3,125. An average cost-per-case savings of 62% was achieved for each patient transferred to the CPC who would have been hospitalized before the inception of the CPC. CONCLUSION: Mandatory stress testing is a safe, cost-effective, and valuable diagnostic and prognostic tool in CPC patients.

Acute Disease↗

PubMed2025

Multiomic Analyses Reveal the Molecular Mechanisms of Arid Adaptation in a Desert Rodent Species.

Organisms living in desert habitats face multiple simultaneous pressures, such as high temperatures and arid, and the population dynamics and community diversity of small rodents are strongly affected by climate extremes. However, the potential mechanisms by which desert rodents adapt to arid remain largely unexplored. Here, we assembled a 3.18 Gb genome, including 25,812 protein-encoding genes, for Orientallactaga sibirica, which is widely distributed across both arid and semihumid environments in Eurasia. Orientallactaga sibirica has longer ears and hind limbs to enhance heat dissipation, which may be related to the positively selected genes, such as Fgf10, Fgf11, Hoxc4, Hoxd1, and Bmp4. The renal transcriptome revealed increased fat and carbohydrate metabolism for metabolic water production in O. sibirica residing in arid habitats. Pathways such as material metabolism, oxidative stress response, osmoregulation, and water and salt reabsorption were enriched in candidate genes, such as Avp, Ang, and Ace, under positive selection in O. sibirica. Moreover, amino acid replacement was observed in the protein sequences of seven candidate genes, including Aldh7a1, Lnpep, Wnk4, C1qc, and Awat2, and these specific amino acid replacements of genes such as Umod and Scnn1a were related to unique osmoregulation, osmotic protection, and water retention compensation mechanisms. Water deprivation under laboratory conditions induced the upregulation of Umod and Aldh7a1 expression, further supporting the results observed in the wild population. These findings demonstrate that the positively selected genes related to limb development and specific amino acid replacements in the genes Umod and Scnn1a for unique osmoregulation in the renal vascular system may contribute to arid adaptation in the desert rodent species O. sibirica. This study provides novel insights into the adaptive evolution of desert small mammals and can serve as a reference for future research on renal damage-related diseases, such as human kidney stones and salt-sensitive hypertension.

Animals↗

PubMed2003

Risk of early surgery for Crohn's disease: implications for early treatment strategies.

OBJECTIVES: In this study we aimed to define the rate of early surgery for Crohn's disease and to identify risk factors associated with early surgery as a basis for subsequent studies of early intervention in Crohn's disease. METHODS: We assembled a retrospective cohort of patients with Crohn's disease diagnosed between 1991 and 1997 and followed for at least 3 yr, who were identified in 16 community and referral-based practices in New England. Chart review was performed for each patient. Details of baseline demographic and disease features were recorded. Surgical history including date of surgery, indication, and procedure were also noted. Risk factors for early surgery (defined as major surgery for Crohn's disease within 3 yr of diagnosis, exclusive of major surgery at time of diagnosis) were identified by univariate analysis. Multiple logistic regression was used to identify independent risk factors. RESULTS: Of 345 eligible patients, 69 (20.1%) required surgery within 3 yr of diagnosis, excluding the 14 patients (4.1%) who had major surgery at the time of diagnosis. Overall, the interval between diagnosis and surgery was short; one half of all patients who required surgery underwent operation within 6 months of diagnosis. Risk factors identified by univariate analysis as significantly associated with early surgery included the following: smoking; disease of small bowel without colonic involvement; nausea and vomiting or abdominal pain on presentation; neutrophil count; and steroid use in the first 6 months. Disease localized to the colon only, blood in the stool, use of 5-aminosalicylate, and lymphocyte count were inversely associated with risk of early surgery. Logistic regression confirmed independent associations with smoking as a positive risk factor and involvement of colon without small bowel as a negative risk factor for early surgery. CONCLUSIONS: The rate of surgery is high in the first 3 yr after diagnosis of Crohn's disease, particularly in the first 6 months. These results suggest that improved risk stratification and potent therapies with rapid onset of action are needed to modify the natural history of Crohn's disease.

Adolescent↗

PubMed2001

How do teenagers and primary healthcare providers view each other? An overview of key themes.

BACKGROUND: Teenagers have often been asked for their opinions about health services. However, relatively few studies have involved quantitative and qualitative methods of assessing them. Furthermore, there have been no United Kingdom studies of providers' views on the health of teenagers or of providers' opinions about their role in teenage health. AIM: To determine how teenagers view primary care, to discover how primary care providers view teenage patients, and to note any differences in opinions between the two groups. DESIGN OF STUDY: Questionnaire survey, focus group discussions, and semi-structured interviews. SETTING: Two thousand two hundred and sixty-five teenage patients, 16 general practitioners (GPs), 12 practice nurses, and 12 general practice receptionists in South Wales valley communities. METHOD: Selected practices provided age-sex registers of patients aged between 14 and 18 years and questionnaires were sent to these patients. Focus groups were assembled from those teenagers who had completed and returned the questionnaire. Semi-structured interviews between one member of the study team and GP surgery staff, chosen randomly from staff lists in the selected surgeries. RESULTS: The teenagers reported a lack of knowledge of services available from primary care, a feeling of a lack of respect for teenage health concerns, poor communication skills in GPs, and a poor understanding of confidentiality issues. The providers did not always share these concerns and they also had differing views on communication and confidentiality issues. CONCLUSION: The data demonstrated important findings about how teenagers would like primary care services to be improved. There was an apparent gulf between teenagers' own opinions about health care and the opinions held by primary care providers.

Adolescent↗

PubMed2005

Genomewide production of multipurpose alleles for the functional analysis of the mouse genome.

A type of retroviral gene trap vectors has been developed that can induce conditional mutations in most genes expressed in mouse embryonic stem (ES) cells. The vectors rely on directional site-specific recombination systems that can repair and re-induce gene trap mutations when activated in succession. After the gene traps are inserted into the mouse genome, genetic mutations can be produced at a particular time and place in somatic cells. In addition to their conditional features, the vectors create multipurpose alleles amenable to a wide range of post-insertional modifications. Here we have used these directional recombination vectors to assemble the largest library of ES cell lines with conditional mutations in single genes yet assembled, presently totaling 1,000 unique genes. The trapped ES cell lines, which can be ordered from the German Gene Trap Consortium, are freely available to the scientific community.

Alleles↗

PubMed2000

Three strategies used by academic health centers to expand primary care capacity.

The growth of managed care in the late 1980s and early 1990s severely disadvantaged academic health centers (AHCs). The reliance on primary care gatekeeping and selective contracting by managed care plans were two contributing factors. Because most AHCs had only a modest primary care capacity, they were understandably concerned about their strategic positions. Thus, many felt it was essential to expand their primary care capacities to ensure downstream referrals, to improve contract negotiations with third parties, and to permit assumption of risk for defined populations. Among the different approaches used, three principal strategies emerged for the expansion of the primary care capacity of AHCs: (1) the "assembly strategy," in which many AHCs recruited new generalist faculty into existing clinical departments; (2) the "acquisition strategy," in which AHCs purchased established primary care practices in the community; and (3) the "affiliation strategy," in which some AHCs affiliated with primary care physicians in the community and formed networks of academic and community physicians. For each of these approaches, the author reviews the relative merits and disadvantages, and analyzes why some AHCs' original assumptions about the imperative for increasing primary care capacity may have been spurious. He concludes that recent marketplace and regulatory changes may make it less necessary for AHCs to secure substantial primary care bases in the future.

Academic Medical Centers↗

PubMed1980

Sickle cell centers of tomorrow. Part I: Regional information centers.

Regional sickle cell organizations are needed to assemble, catalogue, and distribute information, to maintain teaching programs, to serve as referral agencies, and to aid individuals with sickle cell hemoglobinopathies in obtaining maximal benefit from existing community services. The governing body should be representative of the entire area. More than half of the voting members should be adults with the sickle cell trait or sickle cell disease and/or their relatives. A suggested minimal staff could consist of a secretary-librarian and a director. The usefulness of the "Center" to patients, especially at the time of their recurrent painful episodes, could be greatly extended by the maintenance of a 24-hour telephone answering service. Funding of the "Regional Sickle Cell Information Center" by the United Way is recommended.

Anemia, Sickle Cell↗

PubMed1997

Practical guidelines for developing a hospital-based wound and ostomy clinic.

Multidisciplinary teams save time and money while improving quality of patient care. Hospital-based wound/ostomy clinics provide patients with holistic, one-stop, expert care with access to a variety of diagnostic and treatment modalities. The authors discuss how to assemble all the ingredients for a successful multidisciplinary hospital-based clinic, how to make it work, and how to measure its cost-effectiveness for patient, hospital, community and nation. The original model clinic established in Costa Rica using these methods was so successful at providing efficient, high quality, cost-effective care that it has been adopted in 17 different locations there, and similar clinics are being developed in other countries. This model is applicable to industrialized and developing countries. By focusing hospital resources on evidence-based wound/ostomy care, it has the potential to revolutionize wound and ostomy care around the world.

Cost-Benefit Analysis↗

PubMed2026

Metagenomic insights into antibiotic resistance genes and virulence factors in sediments of river Yamuna.

Riverine sediments serve as critical reservoirs of microbial diversity and functional genes, reflecting both natural ecological processes and anthropogenic impacts. In the present study, we employed a shotgun metagenomic approach to investigate microbial community composition, antimicrobial resistance (AMR) genes, and virulence factors in sediments collected from three environmentally distinct locations of the Yamuna River near Agra, India, representing BSA, TGY, and YEA. The sediment DNA was subjected to high-throughput Illumina sequencing, followed by quality control, assembly, and open reading frame prediction. Taxonomic classification and diversity analyses were performed using MEGAN6 and R-based statistical tools, while AMR genes were identified from predicted metagenomic proteins using the Resistance Gene Identifier (RGI) against the CARD database, with high-confidence perfect and strict hits retained; ARGs were interpreted independently of species-level host assignment. Virulence factors were assessed through presence-absence profiling of functionally relevant gene categories. The results revealed pronounced spatial heterogeneity in microbial communities, with increasing taxonomic diversity, functional complexity, and evenness from BSA to TGY and YEA. TGY and YEA composite samples showed greater observed representation of high-confidence AMR gene predictions spanning multiple drug classes and resistance mechanisms, alongside a diverse repertoire of virulence-associated genes linked to motility, adhesion, and secretion systems. In contrast, the BSA site harbored a comparatively simpler resistome and virulome. Overall, this study highlights Yamuna River sediments as important reservoirs of resistance and virulence determinants and underscores the need for long-term genomic surveillance to inform risk assessment, pollution control, and sustainable river management strategies.

AMR↗

PubMed2004

Ethical and programmatic challenges in antiretroviral scaling-up in Malawi: challenges in meeting the World Health Organization's "Treating 3 million by 2005" initiative goals.

The Fifty-seventh World Health Assembly's (WHA's) resolution on the "scaling up of treatment and care within a coordinated and comprehensive response to HIV/AIDS' is welcomed globally, and even more so in Sub-Saharan Africa, where the majority of the people currently in need of antiretroviral therapy do not have access to it. The WHA identified, among others, the following areas which should be pursued by member states and the World Health Organization (WHO): trained human resources, equity in access to treatment, development of health systems, and the integration of nutrition into the comprehensive response to HIV/AIDS. The WHO Director-General was requested to "provide a progress report on the implementation of this resolution to the Fifty-eighth World Health Assembly.' Much of what happens between now and that time depends on the actions of the WHO and the member states and also on the contribution of the international community to the fight against HIV/AIDS. Much of what is to be done will be based on what is available now in terms of practice, human resources, and programs. This paper explores the WHA's resolution, especially regarding the scaling up of antiretroviral therapy, taking Malawi as the case study, to identify the challenges that a Southern African country may be facing which will eventually influence whether the initiative to "Treat 3 Million by 2005' ("3 by 5') will be achieved or not. The challenges southern countries may be facing are presented in this paper not in order to undermine the initiative but to create an awareness of these factors and initiate the appropriate action which would surmount the challenges and achieve the goals set.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Following the leaders in Health for All.

"Leadership Development for Health for All," the theme of the technical discussions at the 41st World Health Assembly in May, was explored by leaders in health and health-related fields, including eminent persons from all walks of life and decisionmakers from the national to the community level. Two prominent nurses were among those who led the debates: Dame Nita Barrow, Permanent Representative of Barbados to the UN, who chaired the discussions, and Eunice Muringo Kiereini, Chairperson of the African Regional Nursing Task Force, who moderated the working group on educational institutions. The principal thrust of the discussions was to engage these leaders in a lively debate, specifically on the issues evolving from three major questions: 1) Why leadership is needed for health for all? 2) What can leadership do in support of health for all? and 3) How can leadership be developed and enhanced? Excerpts from their main conclusions follow.

Delivery of Health Care↗

PubMed2000

Exploring the Phylogenetic Structure of Ecological Communities: An Example for Rain Forest Trees.

Because of the correlation expected between the phylogenetic relatedness of two taxa and their net ecological similarity, a measure of the overall phylogenetic relatedness of a community of interacting organisms can be used to investigate the contemporary ecological processes that structure community composition. I describe two indices that use the number of nodes that separate taxa on a phylogeny as a measure of their phylogenetic relatedness. As an example of the use of these indices in community analysis, I compared the mean observed net relatedness of trees (≥10 cm diameter at breast height) in each of 28 plots (each 0.16 ha) in a Bornean rain forest with the net relatedness expected if species were drawn randomly from the species pool (of the 324 species in the 28 plots), using a supertree that I assembled from published sources. I found that the species in plots were more phylogenetically related than expected by chance, a result that was insensitive to various modifications to the basic methodology. I tentatively infer that variation in habitat among plots causes ecologically more similar species to co-occur within plots. Finally, I suggest a range of applications for phylogenetic relatedness measures in community analysis.

net ecological similarity↗

PubMed1989

Using a national health care data base to determine surgical complications in community hospitals: lumbar discectomy as an example.

To determine the incidence of acute complications of an operation in a large cross-section of U.S. community hospitals, we developed a method that combines the screening of discharge abstracts with the sampling of medical records. Our target patients were those who underwent discectomy for routine lumbar discogenic radiculopathy. We assembled 39,389 discharge abstracts of patients who underwent lumbar discectomy in the U.S. in 1980. This population contained some nontarget patients with a) errors in principal diagnosis or procedure, b) operations exceeding two levels, c) fusion, d) previous laminectomy, or e) problems of the lumbar spine in excess of routine disc disease. Screening of discharge abstracts allowed us to exclude some of these patients. Those remaining were then divided by the reported hospitalization into three groups: 1) death, 2) nonfatal complication, and 3) normal hospitalization. A sample of patients from each group was selected for detailed study, and questionnaires were mailed to hospital medical records departments to confirm the hospitalization and to obtain other medical information unavailable in the abstract. With this information, we 1) removed the remaining nontarget patients (a through e above); 2) categorized reported complications as erroneous, preexistent, trivial or major; 3) calculated the incidence of major complications; and 4) assessed the reliability of the discharge abstract data. Principal diagnosis and procedure were reliably coded in 96.5% of abstracts. No deaths were reported in error and none were excluded in error. Among patients who had complications, 4% of the abstracts incorrectly indicated complications, and 11% omitted one complication while correctly reporting others.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Surveys↗

PubMed1999

Complementing crystallography: the role of cryo-electron microscopy in structural biology.

Dramatic improvements in experimental methods and computational techniques have revolutionized three-dimensional image reconstruction from electron micrographs (EM) of vitrified samples. Recent results include the first determination of a protein fold (for the core protein of the hepatitis B virus) by non-crystalline imaging techniques. These developments have generated interest within the crystallographic community and have led to a re-evaluation of the technique, particularly amongst those working in the field of virus structure or struggling with the phasing of large macromolecular assemblies. A simple discussion of the techniques of EM image reconstruction and its advantages and problems in terms familiar to crystallographers will hopefully allow an appreciation of the essential complementarity of the two techniques and the practical potentials for phasing applications.

Cryoelectron Microscopy↗

PubMed2006

The Type 1 Diabetes Genetics Consortium.

The Type 1 Diabetes Genetics Consortium (T1DGC) is an international, multicenter program organized to promote research to identify genes and their alleles that determine an individual's risk for type 1 diabetes (T1D). The primary goal of the T1DGC is to establish resources and data that can be used by, and that is fully accessible to, the research community in the study of T1D. All the information on T1DGC can be accessed at the following web address: http://www.t1dgc.org. A resource base of well-characterized families is being assembled that will facilitate the localization and characterization of T1D susceptibility genes. From these families, the T1DGC is establishing banks of DNA, serum, plasma, and cell lines, as well as useful databases. The T1DGC also sponsors training opportunities (bioinformatics) and technology transfer (HLA genotyping).

Alleles↗

PubMed1976

Myocardial infarction in car assembly workers.

The incidence of myocardial infarction and the return to work for survivors were studied among the employees of an English car assembly plant by analysing 12 811 medical records of persons employed during the seven years between January 1966 and December 1972. The standardized morbidity ratio of myocardial infarction found in this study calculated on the basis of incidence rates reported by Kinlen )1973) for the Oxford community in which the factory was situated was 90. The standardized morbidity ratio from production line workers only was 66 and that for the monthly paid staff 272. Of the production line workers who survived the attack 22 (90%) returned to their previous jobs without undue difficulty and with two exceptions within four months of the onset of their illness; there was no relation between length of absence and age at the time of attack. These findings suggest that workers in mass production jobs such as car assembly are not special risk from myocardial infarction, and most of those who survive a heart attack are able to return to their former work. Taken with Kinlen's (1973) study and that of Armstrong et al. (1972) in Edinburgh, they also bear out mortality data by indicating that in Oxfordshire the incidence of coronary heart disease is lower than the British average.

Absenteeism↗

PubMed2000

Americans' view of cancer.

This paper presents the concept of the town hall meeting and discusses how it can be used as a forum for those who have been touched by cancer. It can be a platform for people to express their views about cancer, not only in the community but also nationally. Empowerment is the hallmark of a town hall meeting. Those who are in leadership positions in health care and elected officials and community leaders are given the opportunity to hear the opinions of people who represent a broad-based constituency of individuals affected by cancer. The idea of holding a town hall meeting was first introduced in the cancer community by the National Coalition for Cancer Survivorship NCCS) as a means of identifying issues, exchanging information and considering creative solutions to problems. The first town hall meeting was held in 1994 in conjunction with the NCCS annual assembly. Since then, utilizing the guidelines set forth by the NCCS, 30 or more town hall meetings have been held across the United States. Cancer survivors have, by and large, been responsible for garnering the necessary support for conducting a town hall in their local area. Organizations such as the American Cancer Society, the Leukemia Society of America, hospitals, clinics, pharmaceutical and healthcare companies and also noncancer groups, such as the YMCA, churches, and radio/T.V. stations, join with the cancer survivors in organizing the meeting, planning related displays, and advertising the event. In 1998, seven town hall meetings were sponsored jointly by OnCare and NCCS in advance and support of the upcoming THE MARCH- Coming Together To Conquer Cancer, a national rally held in Washington, D.C. in September 1998. Attendees at the meetings included not only cancer survivors and their families, but also healthcare professionals, local and state legislators, community leaders and the media. Results of the 1998 town hall meetings are discussed and compared with the topics identified during the meetings held in 1994-1996. Town hall participants were outspoken about what is needed in America if cancer is truly to become the nation's healthcare priority. They are asking for equal access to quality care, increases in financial backing for research, and more support for cancer advocacy efforts. Benefits of holding town hall meetings are identified.

Health Services Accessibility↗

PubMed2006

Long-term reductions in mortality among children under age 5 in rural Haiti: effects of a comprehensive health system in an impoverished setting.

OBJECTIVES: Evidence regarding the long-term impact of health and other community development programs on under-5 mortality (the risk of death from birth until the fifth birthday) is limited. We compared mortality in a population served by health and other community development programs at the Hôpital Albert Schweitzer (HAS) with national mortality rates among children younger than 5 years for Haiti between 1958 and 1999. METHODS: We collected information on births and deaths in the HAS service area between 1995 and 1999 and assembled previously published under-5 mortality rates at HAS. Published national rates for Haiti served as a comparison. RESULTS: In the early 1970s, the under-5 mortality rate at HAS declined to a level three fourths lower than that in Haiti nationwide. More recently, HAS rates have remained at one half those for Haiti nationwide. Child survival interventions in the HAS service area were substantially higher than in Haiti nationwide although socioeconomic characteristics and levels of childhood malnutrition were similar in both areas. CONCLUSIONS: HAS's programs have been responsible for long-term sustained reduction in mortality among children aged less than 5 years. Integrated systems for health and other community development programs could be an effective strategy for achieving the United Nations Millennium Goal to reduce under-5 mortality two thirds by 2015.

Benchmarking↗